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Best to Avoid Sending Pain Prescriptions By Phone Text

January 3, 2018
The expediency of issuing medical orders by text message is appealing but presents concerns about patient information security and accuracy, as revealed by an Institute for Safe Medication Practices survey.

With Brian C. Drolet, MD

In June, Brian C. Drolet, MD, an assistant professor of plastic surgery and biomedical informatics and the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center in Nashville, Tennessee, discussed the appropriate use of phone texting between practitioners and their patients.1

Since then, the reliance on cell phones for communication has steadily increased while breaches in personal data have raised the stakes on the privacy of patient medical information. These competing interests have redoubled attention on the use of texting for medical orders, particularly for pain practitioners who are under closer scrutiny when appropriately prescribing opioids to manage chronic, intractable pain.

A reported 67% of medical professionals considered it acceptable to text medical orders in the healthcare setting, according to findings reported by the Institute for Safe Medication Practices (ISMP).

Despite ease, there are too many concerns about security, safety, and accuracy of medical information.

ISMP Survey of Text Messaging in the Healthcare Setting 

In response to this information sharing challenge, the Institute for Safe Medication Practices surveyed readers of their professional newsletters about their texting practices regarding medication orders.2

More than 770 newsletter readers responded to the online survey, including pharmacists, nurses, physicians, patient safety officers and risk/quality managers, and educators, nearly all of whom (95%) were based in the United States.3

Safety issues affecting order accuracy and completeness of the medical prescription, more than information security. The five most common risks regarding the practice of text messaging of medical orders identified by respondents were:3

  • Risk of unintended errors due to auto-correct mode
  • Use of abbreviations in text terminology (eg, 2day)
  • Patient misidentification given lack of at least 2 identifiers
  • Spelling errors of patient name, prescribed medication, or correct dose
  • Incomplete order given lack of data prompts, which are typically provided in electronic prescribing systems

The other overriding concerns expressed related to the inability to capture or retain the text message for documentation, and the lack of a verification system with the prescriber or person transmitting the medical order.

Clinical Perspectives and Institutional Policies

More than half (55%) of survey participants had sent text messages to prescribers to elicit clarity for or ask a question about an order, including 65% who were pharmacists, 62% were physicians, and just under half (47%) were nurses.3

Only one-third of those surveyed indicated a problem with the use of phone messaging for medication orders, while another 40% of survey respondents considered the practice acceptable provided an encrypted device application such as Doc Halo or TigerText was employed.3

The findings differed by occupation—26% of physicians responded with a comfort in permitting the use of text messaging in any clinical circumstances while 15% of pharmacists and nurses considered testing appropriate in the medical setting.3

Awareness of Practice Policies is Lacking

Slightly more than half of those surveyed (53%) reported institutional policies prohibiting texts of any medical orders, while the remaining respondents reported no known policy at their facility.Even when policies barring use of phone messaging are in place, many allied health professionals believed medical orders were still being issued by texts, while 36% replied that they were uncertain whether medical orders were being texted or not.

Interestingly, one in five respondents said they had received texted orders regularly by phone: 20% daily and 35% at least once a week;3  as may be expected, of all the professionals, pharmacists received orders most often.

“The benefits of texting orders are primarily related to its popularity and convenience, workflow synergy and speed, and perception of similar risks when compared to other forms of communicating orders,” said the survey authors, “In fact, numerous respondents to our survey noted that, while texting of medical orders is clearly not as safe as electronic prescribing, it may be safer and more timely than verbal or telephone orders.”

However, the authors challenged this perception stating that “verbal or telephone orders can be read back to ensure accuracy and understanding.” Acknowledging that other common methods used to issue medical orders may carry similar risks, the informality of texting medical orders pose significant limitations in data security and medical errors.3

In recognition of the advances in professional standards of practice, policies, and regulations, the Joint Commission reversed its position allowing physicians to avail themselves of the functionality afforded to transmit medical orders via text.4

Despite the apparent adequacy of safeguards, the Joint Commission reversed its position just five months late, issuing a guidance against use of phone messaging to place procedure orders or forward medication prescriptions to pharmacies.5

“In collaboration with the Centers for Medicare & Medicaid Services (CMS), the Joint Commission stated: All health care organizations should have policies prohibiting the use of unsecured text messaging—that is, short message service (SMS) text messaging from a personal mobile device—for communicating protected health information.”According to the Joint Commission, the preferred method for transmitting medical orders remains the computerized provider order entry to ensure accuracy, review, and documentation.

The appeal of sending a text due to the convenience and immediacy must be weighed by the risks of data breaches, unsecured web access, and document retention limitations.

A Biomedical Ethicist Revisits the Pros & Cons of Texting

"There is nothing inherently unsafe about text messaging medical orders, so long as clear and precise communication is used, and verbal or telephone orders are certainly no safer," said Dr. Drolet. 

"When text messages are used to transmit a medical prescription, the information is clearly visible to both the sender and receiver, and any errors from the sender are sure to be caught in the reading. If the receiver has questions, text messaging is two-way and so this allows for clarification, or a phone call can be made for verbal communication," he said.

"In contrast to electronic order entry, there is always two-communication and exchange of information in this format," Dr. Drolet told Practical Pain Management. "If the provider has concerns about liability or risk, then an electronic order entry will leave a better documentation trail," which may be of particular urgency when it comes to pain prescribing, specifically for opioids and other controlled substances, a choice to be made by the prescriber.

"However, for run-of-the-mill communication (eg, continue medications as prescribed, start dose at), a blanket prohibition seems to be unnecessarily risk-adverse and at the cost of expediency for the provider and patient," said Dr. Drolet.

"This same standard is true for the security of all medical information, regardless of the communications form used. In addition, neither of the previous examples imposed a risk of harm from disclosure (despite strict HIPAA regulations), so the application of a one-size-fits-all policy seems overly restrictive," he said.

Last updated on: January 4, 2018
Continue Reading:
The Good Patient: Responsibilities and Obligations of the Patient-physician Relationship

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